Early postoperative imaging and image-guided procedures on patients with face transplants.

Face transplantation is being performed with increasing frequency. Facial edema, fluid collections, and lymphadenopathy are common postoperative findings and may be due to various etiologies, some of which are particular to face transplantation. The purpose of this study was to demonstrate how postoperative imaging and image-guided minimally invasive procedures can assist in diagnosing and treating complications arising from face transplantation. Retrospective evaluation of 6 consecutive cases of face transplantation performed at Brigham and Women's Hospital between April 2009 and March 2014 was performed with assessment of postoperative imaging and image-guided procedures, including aspiration of postoperative fluid collection, lymph node biopsy, and treatment of salivary gland leak. Through these cases, we demonstrate that early postoperative imaging and image-guided procedures are key components for the management of complications following face transplantation.

Restoration of facial form and function after severe disfigurement from burn injury by a composite facial allograft.

Composite facial allotransplantation is emerging as a treatment option for severe facial disfigurements. The technical feasibility of facial transplantation has been demonstrated, and the initial clinical outcomes have been encouraging. We report an excellent functional and anatomical restoration 1 year after face transplantation. A 59-year-old male with severe disfigurement from electrical burn injury was treated with a facial allograft composed of bone and soft tissues to restore midfacial form and function. An initial potent antirejection treatment was tapered to minimal dose of immunosuppression. There were no surgical complications. The patient demonstrated facial redness during the initial postoperative months. One acute rejection episode was reversed with a brief methylprednisolone bolus treatment. Pathological analysis and the donor's medical history suggested that rosacea transferred from the donor caused the erythema, successfully treated with topical metronidazol. Significant restoration of nasal breathing, speech, feeding, sensation and animation was achieved. The patient was highly satisfied with the esthetic result, and regained much of his capacity for normal social life. Composite facial allotransplantation, along with minimal and well-tolerated immunosuppression, was successfully utilized to restore facial form and function in a patient with severe disfigurement of the midface.

Prefabricated and prelaminated flaps for head and neck reconstruction.

Flap prefabrication and prelamination are evolving, new techniques that are useful in reconstructing complex defects of the head and neck. Flap prefabrication involves the introduction of a new blood supply by means of a vascular pedicle transfer into a volume of tissue. After a period of neovascularization, this volume of tissue may be transferred, based only on its implanted vascular pedicle. The transfer may be local transposition or by microsurgical transfer. Flap prelamination refers to a technique in which additional tissue is added to an existing flap (without manipulation of its axial blood supply) to make a multilayered flap that may be used for complex, three-dimensional multilayered reconstructions. This technique may be used locally or at a distance, requiring microvascular transfer. Examples of each are described in this article.

Lip and vermilion reconstruction with the facial artery musculomucosal flap.

The lips are a complex laminated structure. When lost through injury or disease, they present a complex reconstructive challenge. The facial artery musculomucosal (FAMM) flap is a composite flap with features similar to those of lip tissue. In this article, the anatomy, dissection, and clinical applications for the use of the FAMM flap in lip and vermilion reconstruction are discussed. A series of 16 FAMM flaps in 13 patients is presented. Seven patients had upper-lip reconstruction and six had lower-lip reconstruction. Superiorly based FAMM flaps were used in eight patients, and eight inferiorly based flaps were performed in five patients. Three patients had bilateral, inferiorly based flaps. In summary, the FAMM flap is a local flap that can be used for lip and vermilion reconstruction. Although not identical to the lip, it has many similar features, which make it an excellent option for lip reconstruction.

Vacuum-assisted closure in the treatment of degloving injuries.

Degloving injuries range from the occult, easily missed injury to obvious massive tissue damage. The serious nature of these wounds is exacerbated by mismanagement. It is generally accepted that the degloved tissue should be excised, defatted, fenestrated, and reapplied as a full-thickness skin graft. Dressings are required that provide gentle, evenly distributed pressure and avoid shear stress to the newly grafted skin. Numerous types of dressings have been devised but all are cumbersome and time-consuming. We have found the Vacuum-Assisted Closure device to be a rapid, effective, and easy-to-use alternative to traditional methods. The authors examine their experience using a vacuum-assisted closure device to treat nine degloving injuries in 5 patients and discuss the important aspects in using this technique.

Flap prefabrication in the head and neck: a 10-year experience.

Tissue neovascularized by implanting a vascular pedicle can be transferred as a "prefabricated flap" based on the blood flow through the implanted pedicle. This technique potentially allows any defined tissue volume to be transferred to any specified recipient site, greatly expanding the armamentarium of reconstructive options. During the past 10 years, 17 flaps were prefabricated and 15 flaps were transferred successfully in 12 patients. Tissue expanders were used as an aid in 11 flaps. Seven flaps were prefabricated at a distant site and later transferred using microsurgical techniques. Ten flaps were prefabricated near the recipient site by either transposition of a local vascular pedicle or the microvascular transfer of a distant vascular pedicle. The prefabricated flaps were subsequently transferred as island pedicle flaps. These local vascular pedicles can be re-used to transfer additional neovascularized tissues. Common pedicles used for neovascularization included the descending branch of the lateral femoral circumflex, superficial temporal, radial, and thoracodorsal pedicles. Most flaps developed transient venous congestion that resolved in 36 to 48 hours. Venous congestion could be reduced by incorporating a native superficial vein into the design of the flap or by extending the prefabrication time from 6 weeks to several months. Placing a Gore-Tex sleeve around the proximal pedicle allowed for much easier pedicle dissection at the time of transfer. Prefabricated flaps allow the transfer of moderate-sized units of thin tissue to recipient sites throughout the body. They have been particularly useful in patients recovering from extensive burn injury on whom thin donor sites are limited.

Functional reconstruction following electrical injury.

Worldwide, high voltage electrical injury continues to cause significant morbidity, disability, and mortality despite improvements in electrical safety. Joule heating and cell membrane disruption are two mechanisms important in understanding the pathophysiology of electrical injury. The degree of tissue damage is often more extensive than initially perceived on clinical exam. Using modern reconstructive techniques, the functional outcome of electrical injury victims can be improved. The type of reconstruction selected for each injury can be selected from a number of options from the reconstructive ladder. Donor site considerations, risks of the surgery, team experience, and patient preference are important factors in this selection.

Prelaminated free flap reconstruction of complex central facial defects.

This article is a review of five patients who underwent reconstruction of nasal and paranasal facial defects with prelaminated forearm free flaps. The defects resulted from thermal injury, gunshot wound, excision of tumor, and arteriovenous malformation (n = 2). The forearm flaps were based on the radial artery (n = 4) and ulnar artery (n = 1) and were prelaminated with grafts of skin and cartilage. All flaps were successfully transferred to the face, but revisions were needed to separate the subunits and improve appearance. A prelaminated free flap should be considered for a patient requiring reconstruction of a complex central facial defect.

Salvage of externally exposed ventricular assist devices.

Although externally exposed ventricular assist devices are associated with extremely high mortality rates, salvage may be accomplished by early aggressive wound debridement, transposition of a well-perfused autologous tissue (such as omentum), dead space obliteration, and adequate external coverage using vascularized tissue. The temporary suppression rather than the total eradication of the infection should be the goal of these procedures.

Arteriovenous malformations of the head and neck: natural history and management.

This is a retrospective review of 81 patients with extracranial arteriovenous malformation of the head and neck who presented to the Vascular Anomalies Program in Boston over the last 20 years. This study focused on the natural history and effectiveness of treatment. The male to female ratio was 1:1.5. Arteriovenous malformations occur in anatomic patterns. Sixty-nine percent occurred in the midface, 14 percent in the upper third of the face, and 17 percent in the lower third. The most common sites were cheek (31 percent), ear (16 percent), nose (11 percent), and forehead (10 percent). A vascular anomaly was apparent at birth in 59 percent of patients (82 percent in men, 44 percent in women). Ten percent of patients noted onset in childhood, 10 percent in adolescence, and 21 percent in adulthood. Eight patients first noted the malformation at puberty, and six others experienced exacerbation during puberty. Fifteen women noted appearance or expansion of the malformation during pregnancy. Bony involvement occurred in 22 patients, most commonly in the maxilla and mandible. In seven patients, the bone was the primary site; in 15 other patients, the bone was involved secondarily. Arteriovenous malformations were categorized according to Schobinger clinical staging: 27 percent in stage I (quiescence), 38 percent in stage II (expansion), and 38 percent in stage III (destruction). There was a single patient with stage IV malformation (decompensation). Stage I lesions remained stable for long periods. Expansion (stage II) was usually followed by pain, bleeding, and ulceration (stage III). Once present, these symptoms and signs inevitably progressed until the malformation was resected. Resection margins were best determined intraoperatively by the bleeding pattern of the incised tissue and by Doppler. Subtotal excision or proximal ligation frequently resulted in rapid progression of the arteriovenous malformation. The overall cure rate was 60 percent, defined as radiographic absence of arteriovenous malformation. Cure rate for small malformations was 69 percent with excision only and 62 percent for extensive malformations with combined embolization-resection. The cure rate was 75 percent for stage I, 67 percent for stage II, and 48 percent for stage III malformations. Outcome was not affected significantly by age at treatment, sex, Schobinger stage, or treatment method. Mean follow-up was 4.6 years.

Correction of recurrent nipple inversion with cartilage graft.

Of the many techniques advocated to correct nipples, all demonstrate a failure rate with a recurrence of the inversion. We report a technique to correct the recurrent nipple inversion in a simple and permanent fashion. This technique consists of releasing all scar tissue and any lactiferous ducts deep to the nipple and inserting a cartilage graft (rib or auricular) under the nipple. This cartilage graft serves to fill in any soft tissue defect and prevent recurrent contraction and nipple inversion. Although generally used for correction of recurrent nipple inversion, we have also used this technique successfully as an initial modality in patients with inverted nipples. We have found this technique to be simple, nondeforming, cosmetically acceptable, and permanent in the treatment of both inverted and recurrent inverted nipples.

Single-stage, multimodality treatment of soft-tissue sarcoma of the extremity.

The present study describes the techniques available for single-stage sarcoma resection, soft-tissue reconstruction, and radiotherapy for limb preservation in patients who are unable to undergo primary wound closure after a complete soft-tissue resection of their primary sarcoma. From 1989 to 1994, 19 patients (age range, 18-79 years; mean, 51.2 years) underwent radical resection of extremity sarcomas followed by immediate reconstruction. Seven patients had tumors in the upper extremity and 12 patients had tumors in the lower extremity. There were 13 primary tumors and 6 recurrent tumors. Fifteen patients (79%) received radiation therapy, 7 patients by external beam and 8 patients by brachytherapy. Reconstruction included 16 regional flaps in 13 patients and 7 free tissue transfers in 6 patients. Commonly used flaps included the rectus abdominis (N = 5), the latissimus dorsi (N = 4), the anterolateral thigh (N = 4), the reverse-flow radial forearm (N = 2), and the gastrocnemius (N = 2) flaps. Complications included wound breakdown (N = 2), partial skin graft failure (N = 1), hematoma requiring operative evacuation (N = 1), and partial flap necrosis (N = 1). There were no operative mortalities. Eight patients underwent wide local excision, flap closure, and brachytherapy. Mean length of hospital stay for this group was 12.3 days compared with 13.8 days for the remaining 11 patients. There was one complication (13%) in this group and four complications in the remaining patients (4 of 11; 36%). Our study confirms the utility of soft-tissue reconstruction to permit wide local excision with clear margins as well as the delivery of postoperative radiotherapy. It demonstrates the ability of pedicled flaps and free tissue transfers to remain viable and provide sufficient wound coverage in the setting of early postoperative brachytherapy. In addition, this series illustrates the efficacy of a team approach and one-stage therapy for extremity soft-tissue sarcomas that includes excision, reconstruction, and early postoperative brachytherapy in a single hospitalization.

Ear replantation without microsurgery.

Reconstitution of the amputated ear remains a challenge to the plastic surgeon. Reattachment as a composite graft of the total or subtotal amputated ear is unreliable. Microsurgical replantation can be performed in a minority of cases; however, difficulty with adequate venous drainage complicates the technical complexity of these cases. To enhance survival of a reattached ear segment, Mladick et al. advocated use of the retroauricular pocket principle. This technique involves deepithelialization of the amputated part, followed by anatomic reattachment to the amputation stump and then burial in a retroauricular pocket. This simple technique increases the surface area of the avulsed segment in contact with surrounding nutrients, maximizing the probability of "take." The relationship between the dermis and cartilage is preserved, thus minimizing the deformity from cartilage warping. The undisturbed dermis on the involved segment can reepithelialize spontaneously, negating the need for a skin graft. We have used this technique successfully in five of six patients.

An inexpensive method of intraoperative skin stretching for closure of large cutaneous wounds.

A simple and inexpensive method for closure of large wounds is presented. A rib approximator and two spinal needles, which are readily available in most operating rooms, have been utilized to close large cutaneous wounds of the chest and thigh after flap harvest.

Flap closure of postpneumonectomy empyema.

Empyema continues to be an uncommon, frustrating, and potentially lethal complication of pneumonectomy. Between 1990 and 1994 we treated 16 cases of recalcitrant postpneumonectomy (partial or total) empyema with combinations of pulse lavage, sharp debridement, muscle flaps, myodermal flaps, and thoracoplasty. We performed 11 pectoralis muscle flaps, 6 serratus anterior muscle flaps, 9 latissimus dorsi muscle flaps, 6 rectus abdominis muscle flaps, and 1 trapezius muscle flap for an average of 2.1 muscle flaps per patient. There was 1 omental flap. Of these flaps, 2 were free and the rest pedicled. Ten of the muscle flaps carried deepithelialized cutaneous paddles, and 6 were larger than 150 cm3. Thoracoplasty was done in 11 patients to decrease the volume of the postpneumonectomy empyema cavity. Of 16 patients, 4 failed initially because of persistent bronchopleural fistula or infection but resolved after one additional procedure. There was 1 perioperative death, 3 reoperations for bleeding, 1 patient with upper extremity deep vein thromboses, 1 seroma, and 1 patient with significant postoperative pain syndrome. In order to determine the efficacy of different operative approaches, patients were retrospectively divided into two groups according to the number of operations using flaps needed to resolve their postpneumonectomy empyema. Group A required only one operation using flaps to eliminate the postpneumonectomy empyema. Group B required two operations using flaps to remedy the postpneumonectomy empyema. Group B operations were further classified into B1, for the first operation, and B2, for the second operation. No patient needed more than two operations using flaps. Three significant variables were identified, the number of muscle flaps, the number of ribs in any thoracoplasty, and the preoperative serum albumin level. The A and B2 groups had significantly more muscle flaps transposed (p = 0.006) and ribs resected (p = 0.0002) than the B1 group. These findings suggest that filling the postpneumonectomy empyema space with muscle and collapsing any remaining space by thoracoplasty were the most successful strategy. The B2 group's average albumin level was significantly higher (p = 0.03) than that in either the A or the B1 group, suggesting that improved nutrition may have played a role in the lack of recurrence. Our goals of single-stage closure and decontamination of empyema cavities were best achieved by following these principles: removal of infected and necrotic tissue using sharp debridement and pulsed lavage, repair of bronchopleural fistulas with muscle flaps, and minimization of the dead space with combinations of muscle flaps and thoracoplasty.

The use of free tissue transfer in burn reconstruction.

Patients that sustain extensive burns commonly present the reconstructive surgeon with problems caused by exposed tendons, scar contractures, and loss of digits. Frequently there is inadequate local tissue available to solve these reconstructive problems. To solve these complex postburn defects, we have used free tissue transfer in addition to more traditional therapy. From 1987 thru 1994, we have used free tissue transfer as an adjunct to our reconstructive armamentarium in 35 patients who have undergone a total of 45 free tissue transfers for the correction of postburn deformities. There have been two failures (96% flap survival). There were 27 males and 9 females. Twelve free flaps were performed during the initial hospitalization, and 33 were performed during subsequent hospitalizations. Sites of reconstruction included the hand (n = 17), neck (n = 12), face (n = 8), leg (n = 4), penis (n = 2), arm and axilla, 1 each. Flap origin included anterolateral thigh (n = 16), parascapular (n = 10), digital transfer (n = 4), rectus abdominus (n = 3), radial forearm (n = 3), groin, fibula, and foot, two each. Nine flaps underwent prefabrication or prelamination before transfer. In summary, free tissue transfer is a valuable tool in burn reconstruction and it can be used safely and effectively with minimal morbidity to the patient.

Musculofascial flaps based on the dorsalis pedis vascular pedicle for coverage of the foot and ankle.

Soft-tissue reconstruction of the foot and ankle has long presented challenging problems for the plastic surgeon. Limitations of available local tissue, the need for specialized tissue, and donor site morbidity restrict the options available to the reconstructive surgeon. In an effort to solve these difficult problems, we have begun to use musculofascial flaps based on the branches of the dorsalis pedis artery. We present our early experience of 5 patients treated with an extensor digitorum brevis muscle flap with fascial extensions often containing the contents of the first web space. Our patients ranged from 6 to 60 years in age and included 4 males and 1 female. The etiologies of the wounds were secondary to trauma (N = 2), complications of surgery for rheumatoid arthritis (N = 2), and were secondary to a defect following resection of an arteriovenous malformation (N = 1). The flaps had antegrade blood flow in 3 patients and reverse flow in 2 patients. The flaps were covered with a split-thickness skin graft and the donor site was closed primarily. The donor sites healed without the need for further surgery. One patient required additional procedures. This flap proved to be both versatile and effective for closure of difficult wounds of the foot and ankle.

Traumatic avulsion and reconstruction of the midface.

Traumatic loss of midface soft tissue and supporting structures may result in communication between the oral and nasal cavities. Reconstruction requires both oral and nasal lining, as well as supporting structures. The need for multilaminar tissue, as well as the paucity of local tissue, creates a reconstructive challenge. This case report describes the reconstruction of a traumatic defect of the alveolus, hard palate, inferior orbits, and local soft tissues. An intraoperative alginate mold facilitated a three-dimensional understanding of the wound, and allowed translation of an osseomyocutaneous groin flap to reconstruct the defect in one stage.